Healthcare Provider Details

I. General information

NPI: 1033113535
Provider Name (Legal Business Name): SUZANNE DIETZ PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 TYDD ST
EUREKA CA
95501-1284
US

IV. Provider business mailing address

670 9TH ST STE 203
ARCATA CA
95521-6249
US

V. Phone/Fax

Practice location:
  • Phone: 707-269-7051
  • Fax: 707-269-7054
Mailing address:
  • Phone: 707-269-7051
  • Fax: 707-269-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number264132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: